AMARILLO, TX – Health insurers representing more than 50 plans—including major carriers like UnitedHealthcare, Aetna, Cigna, and Blue Cross Blue Shield affiliates—have pledged a set of voluntary reforms aimed at simplifying the prior authorization process for roughly 257 million Americans.
Their agreement, brokered by AHIP, focuses on cutting red tape that often delays treatments and frustrates providers, patients, and payers alike.
At the heart of the initiative are six core commitments:
- Adopting standardized electronic prior authorization via FHIR® APIs, with an 80 percent real‐time approval target by 2027.
- Reducing the overall list of services and drugs subject to prior authorization by January 1, 2026.
- Ensuring continuity of care by honoring existing authorizations for up to 90 days when enrollees switch plans.
- Expanding real‐time responses to further speed up access.
- Improving transparency by clarifying why requests are approved or denied and streamlining the appeals process.
- Guaranteeing that any denied request grounded in clinical judgment undergoes medical review by a qualified professional.
If fully implemented, these measures are designed to slash provider paperwork, accelerate patient care, and cut administrative costs. Success will hinge on how rigorously plans embed FHIR technology, publicly report progress, and collaborate with EHR vendors and provider orgs. Outside observers remain cautiously optimistic: while voluntary, this pact signals industry momentum toward modernizing workflows and may set the stage for future regulatory or legislative action.
These changes come almost a year and a half after CMS published the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) (the “Rule”) on January 17, 2024. The Rule requires payers to implement and maintain a Prior Authorization API that (i) is populated with its list of covered items and services, (ii) can identify documentation requirements for prior authorization approval, and (iii) supports a prior authorization request and response.
The Prior Authorization API must communicate whether the payer approves, denies, or requests more information regarding the prior authorization request. This must be implemented beginning January 1, 2027. The Rule is designed to improve the prior authorization process. Impacted payers must send prior authorization decisions within 72 hours of expedited requests and seven calendar days for standard requests.
Starting in 2026, Payers must provide a specific reason for denied prior authorization decisions, regardless of the method used by providers to submit the prior authorization request. The decisions may be communicated via the portal, fax, email, mail, or phone. This does not apply to prior authorization decisions for drugs. The requirement will allow better communication and transparency between payers, providers, and patients. It will also improve providers’ ability to resubmit the prior authorization request if necessary. Payers must now publicly report their prior authorization metrics annually on their websites.
Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato, PC, a law firm based in Texas with a national health care practice. He represents pharmacies, infusion companies, HME companies, manufacturers, and other health care providers throughout the United States. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or [email protected].
Jacque K. Steelman is a member of the Health Care Group at Brown & Fortunato, PC, a law firm with a national health care practice based in Texas. She represents pharmacies, infusion companies, HME companies, manufacturers, and other health care providers throughout the United States. Steelman can be reached at (806) 345-6316 or [email protected].
